#NHS privatisation or privatisation? - oh - & PFI (Private Finance Initiative)

It is in everyone's interest that when issues relating to the NHS and its future are discussed it is done without misunderstanding or knee jerk reaction. Unless we can do so there can be no rational debate - a debate that allows the best solutions emerge for the very complex challenges the modern day NHS faces.

A key term and one that is often used is "PRIVATISATION" of the NHS. Usually it is used when referencing the threat or perceived threat to the NHS posed by the Conservative Party - ie the Tories are/want to "privatise" the NHS.

There is a problem. "Privatisation" is a loose term. It means different things to different people. Unless it is possible to agree what it means or not mean we will have a problem moving on objectively and collectively - something we need to do desperately.

Here is an attempt to get the terms of reference for a debate about the future of the NHS on a clear footing.

The starting point :

Our National Health System (the NHS) has 3 core principles set down over 60 years ago when the NHS was formed. They are :

1. that it meets the needs of everyone.
2. that it be free at the point of delivery.
3. that it be based on clinical need, not the ability to pay.
   

In relation to those core principles what does "privatisation" mean. There are two possibilities and they are often conflated. They must be separated.

PRIVATISATION (Meaning 1) It means getting rid of the NHS as defined above and replacing it with another system - most likely an insurance based scheme as used in the USA and many other countries. (private health care). People who advocate this do so because they believe the NHS is inefficient, too costly, possibly too big to control and too unwieldy to meet future challenges and needs. Their conclusion is it is unsustainable and needs to be replaced by a better system. That better system will be paid for by individuals out of their own money - probably with the benefit of tax relief on premiums paid. For some it might simply be they see the possibility of making a great deal of money out of a new system.

PRIVATISATION (Meaning 2) It means the core principles of the NHS above are fully retained ie free to everyone based on need rather than the ability to pay but with the private sector (funded out of taxation) providing some/all of the services and treatments offered by the NHS.

Advocates of the private sector playing a part in the provision of NHS services and treatments might argue any of the following :

• It can offer choice.
• It can be more flexible.
• It can be niche.
• It can be more efficient ie the NHS becomes the customer rather than the provider. As such it can determine the contract and what it is prepared to pay for. This can encourage/require the provider to offer excellent service/results.
• It can sometimes offer better value for tax payers money than the NHS can provide for the same money.
• The private sector is often more innovative.
• The private sector can be more efficient and offering volume treatments such as immunisation injections - flu jabs - screening etc.
• It can be a way of the NHS obtaining new capital investment albeit indirectly. 

However there is plenty of opposition to this type of privatisation. Arguments against might be any of the following :

• For some it is emotionally and/or politically unacceptable to introduce "private" (and therefore profit motive) under any circumstances into the NHS.
• It is the thin edge of the wedge - a slippery slope. Those advocating Privatisation Meaning 2 are actually aiming for Privatisation Meaning 1 in the longer term.
• It must cost the NHS (tax payer) more because some money is being taken out of the system as corporate profit.
• Private puts profit before patient interest.

OBJECTIVITY NEEDED - MY ASSESSMENT (a personal  and lay opinion).

1. I do not believe any of the major political parties - including the Conservatives - want to Privatise the NHS as in Meaning 1 above as part of their manifesto or even hidden agenda. Apart from anything else it would be political suicide. 
2. However ALL parties faced in government with running and financing the NHS quickly realise how challenging it is to both fund and to meet public expectation.
3. Those that advocate everything provided publically (without profit motive) is good and everything provided by the private sector through Meaning 2 must be bad because there is a profit motive are being doctrinaire rather than objective.
4. The NHS is still almost entirely over (95%) outright public in its provision but bad care happens (South Staffs). Mistakes happen. Waiting lists happen. Targets aren't met. Over bloated management happens. Money is wasted - paying too much for drugs etc.
5. Some argue that 4 above is entirely because the NHS does not have enough money - or even - money should not even be a consideration in healthcare.
6. However resources come from taxation and are therefore finite. Choices have to be made about what is spent where. A terminally ill cancer patient can be given a very expensive drug that might extend life by 6 months to a year. That money could be spent on providing an extra nurse for a year and would help many patients. What is the right thing to do?
7. It is well documented and understood by the baby boomers (of which I am one) that the "public sector" can be very inefficient and wasteful. They are usually both monolithic and monopolistic - and as a result can be unresponsive to customers - badly managed - complacent and self serving. Not a panacea. We have experienced it first hand
8. As a result, past Labour and Conservative (and with the Liberal coalition) have seen there is a place for some limited privatisation under the NHS public umbrella. GP's and dentists are effectively "private businesses". Hospices are businesses albeit charity based ones. Many outpatient clinics are now run by private contact (such as Virgin) - for which the NHS pays and of course so are many support services - like IT, cleaning and catering. It is happening and by and large it works very well and there might be scope and reason to do more.
9. For me (8 above) is not an issue providing the NHS sets the clinical/medical standard. The important thing is not whether a particularly service is carried out by the Public or Private sector providing any private contract outsourced by the NHS - is paid for by the NHS and is free to the public based on clinical need rather than an ability to pay. Surely the most important focus is the quality of the service provided and not really who provides it.

So in summary I think the NHS is too big and the issues too complex for a one cap fits all mind set. The NHS must continue to challenge itself - find the optimum way of doing things - and the public would be irrational to be dismissive of private providers if they can offer a quality and cost effective service (for less money.) There is no doubt in my mind Public owned businesses can be wasteful and complacent and in some situations private business can do a better job.

A quick word about PFI contracts for those that do not know much about it. Private Finance Initiatives are very much in the news at the moment. Broadly these contracts/schemes started when Blair/Brown were running the Government. 75% of all existing PFI contracts were signed by a Labour Government. What are they? The Labour Government decided they want to provide new hospitals, schools and roads. However they do not want to pay for it by raising taxes. They could borrow the money - but that looks bad too. So what do they do? They find a private company to build the hospital, or school or motorway. The private company pays for it all before handing the completed building over to the NHS/Government. Look voters we have provided you with a brand spanking new hospital - vote for us! The deal is then the NHS/Government repay the private company over say a 30 year period. However now the penny has dropped - or been exposed - which is why it is in the news. Billions are outstanding to PFI companies and is costing a fortune to service. The tax payer will be paying through the nose for years and it is the Governments fault. There should be a lesson here for all those that want to consume now and pay for it later. Sooner or later the sh-t hits the fan. Better to try and live within your means. Morally better to live within your means than dump the liability on the next generation (your kids!)